On Wednesday, October 2, the Centers for Medicare and Medicaid Services (“CMS”) issued its 2015 consultation guide for states to use when setting reimbursement rates with respect to any Medicaid managed care program subject to actuarial soundness requirements in 42 CFR 438.6 during rating periods starting January 1, 2015. The guide “describes information that CMS expects states to provide when developing the actuarial rate certifications.” Continue reading
Tag Archives: Medicaid
Office of the Inspector General of the federal Department of Health and Human Services (“OIG”) has issued a report that suggests that most states that offer Medicaid through Managed Care Organizations (“MCOs”) have widely-variable and possibly inadequate oversight of the organizations providing care to Medicaid beneficiaries. Given OIG’s findings, beneficiaries, providers, and Medicaid MCOs should not be surprised if federal guidelines or regulations emerge that move toward standardizing access requirements and compliance assessments in Medicaid managed care. Continue reading
According to United States Attorney Richard S. Hartunian, the City of New York (NYC) has agreed to pay the United States Department of Justice (US DOJ) $1.05 million to settle allegations that the NYC Human Resources Administration (HRA) violated the federal False Claims Act by causing various managed care organizations (MCOs) to provide Medicaid coverage to individuals that HRA knew, or should have known, were ineligible to receive New York State Medicaid benefits because they had moved outside New York State. The case was brought by a whistleblower and investigated by the US DOJ and United States Department of Health and Human Services Office of the Inspector General (OIG). Continue reading
The New York State Office of the State Controller (“OSC”) has released its audit of the New York State Office of the Medicaid Inspector General (“OMIG”) entitled “Accuracy of Reported Cost Savings.” The final report, issued July 11th, presented OSC’s findings regarding the accuracy of the OMIG’s reported cost savings for calendar years 2008 through 2012. Continue reading
Attention OMH Continuing Day Treatment Providers: OIG Releases Audit of CDT Programs, Seeks Repayment of over $18 Million to Federal Medicaid Program
The United States Department of Health and Human Services Office of the Inspector General (“OIG”) conducted an audit of New York State’s nonhospital-based Continuing Day Treatment (“CDT”) program.
CDT services are clinic services administered by the New York State Office of Mental Health (“OMH”). OMH’s CDT program provides Medicaid recipients with treatment designed to maintain and/or enhance current levels of functioning and skills, to maintain community living, and to develop self-awareness and self-esteem through the exploration and development of strengths and interests. CDT services include, but are not limited to, assessment and treatment planning, discharge planning, medication therapy, case management, psychiatric rehabilitation, and activity therapy.
To be eligible for the CDT program, a recipient must have a diagnosis of a designated mental illness as well as a dysfunction due to a mental illness. The recipient’s treatment plan must be completed in a timely manner; be signed and approved by both the recipient and the physician involved in the treatment; include a diagnosis of a designated mental illness, treatment goals, objectives, and related services, a plan for the provision of additional services, and criteria for discharge planning; and be reviewed every 3 months. Additionally, progress notes must be recorded at least every 2 weeks by the clinical staff members who provided CDT services to the recipient. The progress notes must identify the particular services provided and the changes in goals, objectives, and services, as appropriate. In addition, CDT services must be adequately documented, including type, duration, and need for continuing services.
The OIG audit report alleges that New York State claimed federal Medicaid reimbursement for nonhospital CDT services that did not comply with federal and State requirements. Of the 100 claims in the OIG’s random sample, 66 claims complied with federal and State requirements, while 34 claims allegedly did not. The audit period was from April 1, 2009 to August 17, 2011.
According to the OIG audit report, the alleged deficiencies occurred because (1) certain nonhospital CDT providers did not comply with federal and State regulations and (2) the State did not ensure that OMH adequately monitored the CDT program for compliance with certain federal and State requirements. On the basis of the sample results, the OIG estimated that the State improperly claimed at least $18,093,953 in federal Medicaid reimbursement for nonhospital CDT services that did not meet federal and State requirements.
The OIG recommended that the State refund $18,093,953 to the Federal Government; work with OMH to issue guidance to the provider community regarding federal and State requirements for claiming Medicaid reimbursement for nonhospital CDT services; and work with OMH to improve OMH’s monitoring of the CDT program to ensure compliance with federal and State requirements.
According to the OIG audit report, New York State responded as follows
. “In written comments on our draft report, the State agency disagreed with our first recommendation (financial disallowance) and did not indicate concurrence or nonconcurrence with our remaining recommendations. Specifically, State agency officials stated that we based our findings entirely on State regulations and, if OMH found claims to have violated the State regulations we cited, those violations “would not have rendered the services non-reimbursable.” The State agency also disagreed with our determination that, for one sampled claim, progress notes were not prepared by a staff member who provided a service. Specifically, State agency officials stated that, for the sampled claim (#73), a progress note clearly demonstrated that “the treatment provider was actively engaged” with the beneficiary during the 2-week period that included the sampled service date. In addition, the State agency disagreed with our determination that certain sampled claims did not meet reimbursement standards. State agency officials indicated that their preliminary analysis of our workpapers revealed that providers supplied us with schedules of group services that beneficiaries were scheduled to attend each day they visited the CDT provider. State agency officials stated that these schedules document the frequency and types of services planned for each beneficiary.”
As a result of the OIG audit, it is likely that the New York State Office of the Medicaid Inspector General (“OMIG”) will be conducting additional audits of CDT providers.
The OIG audit report is available at http://oig.hhs.gov/oas/reports/region2/21201011.pdf.
For more information, please contact the author, David R. Ross, who served as Acting New York State Medicaid Inspector General under governors Pataki and Spitzer, as well as General Counsel, Deputy Medicaid Inspector General, and Director of Audits and Investigations for the Office of the Medicaid Inspector General (OMIG). He can be reached at (518) 462-5601 or via e-mail at email@example.com.
Attention Medicaid and Medicare Providers: US DOJ Sues Providers for Failing to Return Overpayments Within 60 Days
On June 27, 2014, in the case of United States ex rel. Kane v. Healthfirst, Inc., et al., No. 11-2325 (S.D.N.Y.), the United States Department of Justice (USDOJ), via the United States Attorney’s Office for the Southern District of New York, sued several Medicaid providers under the federal False Claims Act for failing to return Medicaid overpayments within 60 days of identifying them. Continue reading
The New York State Office of the Medicaid Inspector General (“OMIG) has released its State Fiscal Year 2014-2015 Work Plan. You can find the press release at: http://www.omig.ny.gov/latest-news/764-2014-15-work-plan
The Work Plan is a road map of where the OMIG intends to go in terms of its anti fraud, waste and abuse efforts within the Medicaid program. The OMIG’s mission is one of “preventing and detecting fraudulent, abusive, and wasteful practices within the Medicaid [program and recovering improperly expended Medicaid funds while promoting high quality patient care.” The Work Plan intends to “fight fraud, improve integrity and quality, and save taxpayer dollars.”
According to the Work Plan, the OMIG has established nine “business line teams” that each consist of multiple OMIG personnel from various functional areas within the OMIG that work as a team. The goals of these specialized, multidisciplinary teams include improved efficiency, more thorough reviews and investigations, and reduced time to completion.
Broad areas of Medicaid service provision that the OMIG has established business line teams for include, but are not limited to, the following: home and community care services; hospital and outpatient services; managed care; medical services in an educational setting; mental health, chemical dependence and developmental disabilities services; pharmacy and durable medical equipment; physicans, dentists and laboratories; residential health care facilities; and transportation. Each business line will face varying degrees of scrutiny by the OMIG during this state fiscal year. There is a discussion of each area in the Work Plan available at: http://omig.ny.gov/images/stories/work_plan/2014-15_work_plan.pdf
In addition to the Business Line Teams discussed above, the OMIG also conducts various activities that relate to Medicaid program integrity across multiple business lines. The OMIG is again emphasizing the requirement for Medicaid providers to have an effective compliance plan, and the OMIG will be reviewing compliance plans for effectiveness. Part of an effective compliance plan, and the most significant part as far as the government is concerned, is the ability of the provider to identify and return Medicaid overpayments that the provider has received. The 60 day “report, repay and explain” self-disclosure requirement imposed by the federal Affordable Care Act is also a game changer. The OMIG will continue to review providers who do not make periodic self disclosures or who have never made such disclosures.
The areas listed in the OMIG’s Work Plan that cross multiple business lines are as follows:
Ambulatory Patient Groups
Collaborative Efforts with Law Enforcement/Medicare Fraud Strike Force
Collaborative Managed Care Surveys
Compliance Program General Guidance and Assistance
Compliance Program Reviews
Corporate Integrity Agreement Enforcement
County Demonstration Program
Enrollment and Reinstatement
Estate and Casualty Recovery
Fee-for-Service Third-Party Retroactive Recovery Projects
Kickbacks and Inducements
Location of Services Unknown to New York State Department of Health
Managed Care Third-Party Retroactive Recovery Projects
Medicaid Consumer Investigations
Medicaid Electronic Health Records Incentive Payment Program
Medicaid Integrity Contract Audits
Medicaid Recovery Audit Contractor
Medicare Coordination of Benefits with Provider-Submitted Claims
Patient Protection from Disqualified Providers
Payment Error Rate Measurement Project
Prepayment Insurance Verification
Third-Party Liability and Commercial Direct Billing
There will be a continued emphasis on excluding those providers who commit fraud and abuse. Those who commit “inappropriate and fraudulent acts” will face exclusion from the Medicaid program, then, by operation of law, exclusion from the Medicare program, and in essence become virtually unemployable by most health care providers who accept federal funds.
If you would like to discuss any of the areas identified in the OMIG’s Work Plan, or anything else related to the Medicaid program, please feel free to contact the author of this article, David R. Ross, Esq., who was formerly New York State’s Acting Medicaid Inspector General under Governors Pataki and Spitzer. Mr. Ross was also the Director of OMIG audits and investigations as well as the OMIG’s General Counsel. He can be contacted via e-mail at firstname.lastname@example.org or reached by telephone at (518) 462-5601.
The New York State Office of the Medicaid Inspector General (OMIG) has announced that it has recovered $851 million in Medicaid funds for 2013. If accurate, this amount will have set a new record (the prior record is claimed to have been $468 million for 2012) for the OMIG in a state where over $53 billion is spent annually on Medicaid. According to the Daily News, more than one half of the $851 million in recoveries, $496 million, originated from a settled dispute with the federal government about whether Medicare (vs. Medicaid) should have been billed for certain home health services. If the $851 million figure is reduced by the amount of the federal settlement, the amount recovered by the OMIG becomes $355 million for 2013.
Governor Cuomo issued a press release on the OMIG recoveries. “With more than $851 million recovered from Medicaid abuses in 2013 alone – the most in the State’s history – New York is truly leading the nation in fighting fraud and protecting taxpayer dollars,” Governor Cuomo said. “Our focus on cleaning up the Medicaid program is showing record-breaking results, and OMIG’s efforts serve as a role model for other states to follow. Eliminating this kind of waste is vital to transforming New York’s healthcare system, and this year’s tremendous amount of recoveries shows that we are well on our way to building a healthier and fairer New York.”
“Fighting Medicaid fraud is a cornerstone of our efforts, and anyone who steals from Medicaid should know that we will find them. OMIG is proud of this record result,” said Medicaid Inspector General James C. Cox. “This is an extraordinary accomplishment, and an historical achievement. Through dedication and perseverance, our staff not only met but exceeded all expectations in recoveries for the year. Governor Cuomo’s support was crucial to our efforts.”
The OMIG’s mission is “to enhance the integrity of the New York State Medicaid program by preventing and detecting fraudulent, abusive, and wasteful practices within the Medicaid program and recovering improperly expended Medicaid funds while promoting a high quality of patient care.”
The Daily News article can be found here: http://www.nydailynews.com/new-york/ny-recoups-851-million-medicaid-funds-article-1.1599885. Governor Cuomo’s press release can be found here: http://www.governor.ny.gov/press/02032014-medicaid-recoveries.
For more information, please contact the author, David R. Ross, who served as Acting New York State Medicaid Inspector General under governors Pataki and Spitzer, as well as General Counsel, Deputy Medicaid Inspector General, and Director of Audits and Investigations for the Office of the Medicaid Inspector General (OMIG). You may call David at 518.462.5601 or e-mail him at email@example.com
The New York State Office of the Medicaid Inspector General announced on October 30 that it has recovered the single largest monetary recovery in its history, a sum of $211 million. The repayment stems from an investigation of payments made on behalf of dually-eligible individuals, who are eligible for both Medicaid and Medicare. The overpayments were identified within the Third Party Liability Home Health Care Demonstration Project, which targeted dual-eligible populations who received home health care.
Notably, the audit that led to this recovery was conducted using a sampling technique, rather than an individual, case-by-case analysis of each claim submitted. The audit indicated that in some cases, Medicaid was billed first for services rendered to the beneficiary and then Medicare was billed, rather than the other way around.
The OMIG’s press release in this matter may be viewed here: http://www.omig.ny.gov/latest-news/697-496-million
Caitlin Monjeau contributed this post.
Today, CMS issued a Press Release announcing that it is conducting a demonstration project with New York State known as the Fully Integrated Duals Advantage (FIDA) demonstration. Under this capitated demonstration, approximately 170,000 New Yorkers who are people eligible for Medicaid and Medicare in NYC, Long Island and Westchester County will be able to join a health plan that includes all the benefits of under Medicare (Parts A and B, and Part D) and Medicaid and additional support for care coordination and community living. Those who are eligible can opt in starting in July 2014 for community based individuals and October 2014 for individuals living in nursing homes. Continue reading